RECEIPT NO. _______________

                                                 ACCT. NO. _________________

                                                 DATE ______________________

APPLICATION FOR RESIDENTIAL WATER SERVICES

NAME _____________________________ SERVICE ADDRESS __________________________

MAILING ADDRESS _____________________________________________________________

_____________________________________________________________________________

DATE OF SERVICE _____________________________ PHONE NO. _____________________

OWN _____ BUYING _____ RENTING _____ NAME OF LANDLORD _______________________

SINGLE __________

MARRIED __________ NAME OF SPOUSE ___________________________________________

EMPLOYMENT ________________________________________ PHONE ___________________

SPOUSE EMPLOYMENT _________________________________ PHONE ___________________

HAVE YOU EVER HAD WATER SERVICE IN ROSWELL? _____ IF SO, WHERE? _____________

IN ORDER FOR WATER TO BE TURNED ON, ALL FAUCETS, WASHER CONNECTIONS, ETC.,
MUST BE OFF.  THE SERVICE PERSONNEL ARE NOT ALLOWED TO GO INSIDE YOUR HOUSE.

                                    SIGNATURE ______________________________

CUSTOMER WILL BE RESPONSIBLE FOR WATER USED PRIOR TO CHECKING INTO SERVICE

OFFICE USE ONLY

DL# _____________________

SS# _____________________

DOB _____________________

City of Roswell     Post Office Box 1838     Roswell, New Mexico 88202-1838

             (505) 624-6711          (505) 624-6709 - Facsimile